Comparative Effectiveness of Nonoperative Treatments for Acute Anterior Epistaxis in Emergency and Otolaryngology Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Acute anterior epistaxis is frequently managed with multiple nonoperative interventions, but comparative evidence regarding their effectiveness remains uncertain. This systematic review and meta-analysis evaluated the effectiveness and safety of nonoperative treatments for acute anterior epistaxis in emergency and otolaryngology settings. PubMed/MEDLINE, Scopus, and Web of Science were searched from inception through 3 July 2026 for randomized controlled trials (RCTs) comparing nonoperative hemostatic interventions in adults with acute anterior epistaxis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and random-effects meta-analysis was performed when sufficient clinical comparability was present. Nine RCTs including 1,124 participants were identified, with three trials contributing to quantitative synthesis. Topical tranexamic acid reduced rebleeding within 24 hours compared with matched vehicle controls (RR, 0.39; 95% CI, 0.17-0.89), with an absolute risk reduction of 19.1 percentage points. However, topical tranexamic acid was not associated with a significant reduction in further hemostatic intervention (RR, 0.59; 95% CI, 0.22-1.59). Other nonoperative strategies showed variable effects across heterogeneous outcomes. Overall, topical tranexamic acid may reduce early rebleeding in acute anterior epistaxis, but evidence regarding broader clinical outcomes remains limited by the small number of comparable trials, heterogeneous protocols, and inconsistent outcome definitions. Further high-quality randomized trials with standardized outcomes are required to clarify the optimal role of these interventions.